The Treatment of Cubitus Valgus Using the Ilizarov Method

MOJ Orthopedics & Rheumatology

Abstract Research Article

Cubitus valgus is the most common complication of lateral condylar fractures. Volume 3 Issue 3 - 2015 Various combinations of osteotomy and fixation have been described to correct valgus deformity. We are using distraction osteogenesis with Ilizarov technique Bari MM1*, Shahidul Islam2, Shetu NH2, to treat 11 elbows in 11 patients with cubitus valgus. The clinical outcome was 2 2 evaluated using the protocal of Bellemore et al. [1]. The mean time to follow up Mahfuzer Rahman and Masum Billah Md was 20 months (15 to 35) and the mean time to Ilizarov frame removal was 14 1Chief Consultant, Bari-Ilizarov Orthopaedic Centre, Visiting and Honored Prof., Russian Ilizarov Scientific Centre, Russia 2Bari-Ilizarov Orthopaedic Centre, Bangladesh goodweeks results. (10 to 18). The mean carrying angle was corrected from 35˚ (25˚ to 40˚) Mofakhkharul Bari, Chief to 10.4˚ (5˚ to 15˚) in patients with cubitus valgus. There were 8 excellent and 3 *Corresponding author: Consultant, Bari-Ilizarov Orthopaedic Centre, Visiting Keywords: Cubitus valgus; Ilizarov; Osteotomy Kurgan, Tel: +88 01819 211595, Email: and Honored Professor, Russian Ilizarov Scientific Centre, Introduction Received: August 14, 2014 | Published: September 15, 2015 The Ilizarov technique with gradual controlled coordinated stretching is a safe and versatile method of treating cubitus valgus deformity at the elbow without the problems of an unsightly scar or limited range of movement and gives a good clinical and joint line is marked on the radiograph. Next a line is drawn at an radiological outcome. The pre-operative planning is carried out as follows: at first, the (the valgus inclination line/angle). A line perpendicular to thus is Fracture of the lateral condyle is the most common fractures constructedangle of 6˚ to (the 8˚ to distal establish vertical the line) normal which valgus crosses angle the of anatomical the elbow of the elbow in children [2-4]. In cubitus valgus malunion is very axis of the humerus at the centre of rotation of angulation (CORA). common. A line bisecting the obtuse angle of this intersect represents the Most of the operations are associated with technical problems line of osteotomy. and complications [5]. These include under or overcorrection, neuropraxia, an unsightly scar, refracture at the osteotomy site, posterolateral aspect of the lateral condyle and is passed to limitation of range of movement at the elbow, infection and nerve The first (distal reference) wire is inserted from the injury. inclination to the joint line. The second wire is inserted from the We have used distraction osteogenesis by Ilizarov technique posteromedialthe anterior cortex aspect of of the the medial medial epicondyleepicondyle atand 6˚ passed to 8˚ valgusto the for the treatment of patients with cubitus valgus [6]. It differs anterior cortex of the lateral condyle. These two wires should be from the others by applying the principles of deformity correction olive-tipped to avoid translation of the distal half circle. A second described by Ilizarov [6]. full circle is then applied approximately 4.0 cm to 5.0 cm above the apex of the deformity. A motor unit is then placed on the Materials and Methods hinge at the line of osteotomy on the convex side of the deformity We treated 11 elbows in 11 patients by osteotomy and gradual isconcave aligned aspect with ofthe the centre frame of at rotation 90˚ to theof angulation. axis of the Anhinges. opening The controlled coordinated stretching using the Ilizarov method. wedge correction is achieved without any translation, shortening There were 8 boys and 3 girls with a mean age of 13 years (7 to or lengthening (Figure 1a-1c). A third full circle can be applied as 16). Cubitus valgus occurred after a fracture of the lateral condyle necessary above the second in the same manner. All the wires are in 11 patients. Four patients with cubitus valgus had a tardy ulnar nerve palsy. We did not do any ulnar transposition of the nerve small incision is made over the apex of the deformity. but we observed surprisingly that gradual distraction relieved the inserted under image intensification. After applying the frame, pain due to neohistogenesis. After carrying out the osteotomy, all the clamps and nuts Surgical Technique The surgical intervention was carried out with the patient are re-tightened and the final position checked with the image intensifier.Post-operatively, all wire sites are cleaned meticulously with supine and the affected arm on a arm table. We did the surgery antiseptics. without tourniquet.

Figure 1:

a) The pre-operative Diagrams showing plan. The the most Ilizarov distal method dotted of line fixation is the for joint cubitus line. valgusThe valgus inclination line is set at 6o to 8o to the joint line in the coronal plane. The line perpendicular to this is the axis of the humerus of the centre of rotation of angulation. The upper dotted line bisects the obtuse angle of this intersect and represents the line of osteotomy. b) The humeral frame. The lower humeral angle formed is at the level of the valgus inclination line, and the upper humeral ring at the level of the middle third of the diaphysis. c) The hinge is at the level of the bisector line and lies over the medial bisector line osteotomy opened cortex around the centre of rotation of angulation, thereby correcting the deformity.

Discussion placeElbow four and times shoulder a day exercises (0.25x4=1 were mm started per day).on the Distraction first post- wasoperative continued day. Distractionuntil full correction was started of afterthe deformity five days had and been took stage, further adjustment of the osteotomy is not possible even Since most techniques achieve a definitive correction in one achieved. The results were evaluated according to the system of if needed. The anatomy of the supracondylar region makes its

Barrats et al. [1]. A carrying angle of ≤5˚ and limitation of flexion difficult to maintain the correction of any deformity by internal fixationIn our with series, Kirchumer we strictly wire, followed plates and the screws principles [4,5]. of deformity and extension by ≤10˚ was considered on excellent outcome. A correction proposed by Academician Prof Ilizarov [6-8]. We carrying angle of 6˚ to 10˚ and limitation of flexion and extension did not transpose the ulnar nerve in our four patients and they beby a≤20˚ poor was outcome. considered a good outcome and a carrying angle of recover after correction of cubitus valgus due to distraction >10˚ and loss of flexion and extension of ≥20˚ was considered to histoneogenesis. Acute correction can cause a traction injury of Results the ulnar nerve. The way that we have done the osteotomy and The mean period of follow up was 20 months (15-40), the mean gradual controlled coordinated stretching procedure did not time to removal of Ilizarov from was 14 weeks (10-16 months). worsen a preexisting tardy ulna palsy, rather it improved the neurological problems. All patients had an excellent (8 elbows) or good (3 elbows) outcome. The mean preoperative carrying angle of the patients Different authors have reported hypertrophic scars [4,5,9]. We did not encounter this because of mini stab incision required. The gradual correction of cubitus valgus by distraction tardywith cubitusulnar nerve valgus palsies, was 35˚ who (25˚-40˚). did not The undergo mean a carrying transposition angle osteoneogenesis has other advantages. The position of the procedure,at the last relieved follow up pain was with 8˚ (3˚-13˚).the successful The four correction patients of with the distal fragment can be adjusted in all planes until complete deformity through distraction histoneogenesis: All minimal consolidation has occured. The elbow does not become stiff because the patient can start their exercises immediately. At and proper dressings without any problems. the end of distraction period, we must evaluate the upper limb superficial pin tract infection were treated with oral antibiotics Figure 2: Case 1 clinically and radiologically. Any additional deformity can be corrected easily. We must mention that most of our patients are Figure 3: Case 2 teenagers.

Citation: Bari MM, Islam S, Shetu NH, Rahman M, Md MB (2015) The Treatment of Cubitus Valgus Using the Ilizarov Method. MOJ Orthop Rheumatol 3(3): 00096. DOI: 10.15406/mojor.2015.03.00096 Copyright: The Treatment of Cubitus Valgus Using the Ilizarov Method ©2015 Bari et al. 3/6

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Figure 2: Case 1 1. 9 years old girl, nonunion lateral condyle, left cubitus valgus with tardy ulnar nerve palsy. 2. Left deformed elbow. 3. Left cubitus valgus 9 years old girl, elbow in extension. 4. One month after osteosynthesis with Ilizarov (opening wedge valgus osteotomy). 5. After two months post. op. 6. Radiographic view of left elbow with Ilizarov in situ after one month follow up. 7. Radiograph of lateral condyle fracture with cubital valgus and open wedge osteotomy of left humerus. 8. Just after removal of the Ilizarov apparatus. 9. Radiographic union of left lateral condyle and correction of left cubitus valgus. 10. Radiographic union of left lateral condyle and correction of cubitus valgus is achieved (lateral view). 11. After 2½ months follow up. 12. Radiographic results after 3½ months.

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Figure 3: Case 2: 1. 14 years old boy left cubitus valgus elbow in extension. 2. Flexion position before surgery. 3. Smilling patient with Ilizarov apparatus in the left humerus. 4. Full correction of left cubitus valgus with Ilizarov apparatus in situ after 1 month follow up. 5. Lateral view of left humerus with Ilizarov apparatus after one month follow up. 6. Radiographic view of opening wedge osteotomy with placement of hinges over the CORA (Center of rotation of angulation) after 2 months follow up. 7. Patient is doing exercises with Ilizarov apparatus. 8. Patient can continue exercises with the Ilizarov apparatus. 9. Clinical appearance of the patient after 3 months follow up (front view in extension of elbow).

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16 17 Figure 3: Case 2: 10. Clinical appearance of the patient after 4 months follow up. 11. Clinical appearance of the patient after 3 months follow up (front view). 12. Clinical appearance of the patient after 3 months follow up (back view in abduction). 13. Clinical appearance of the patient after 3 months follow up (back view in extension of elbow). 14. Final radiographic result after 4 months follow up. 15. Clinical appearance of the patient after 4 months follow up. 16. Clinical appearance of the patient after 4 months follow up. 17. Clinical appearance of the patient after 4 months follow up.

Conclusion 3. Gaddy BC, Manske PR, Pruitt DL, Schoenecker PL, Rouse AM (1994) Distal humeral osteotomy for correction of posttraumatic cubitus Cubitus valgus deformity of the elbow by distraction varus. J Pediatr Orthop 14(2): 214-219. Hasler CC (2003) correction of malunion after pediatric supracondylar safe, stable, reliable and unique method which avoids unsightly 4. osteoneogenesis with an Ilizarov method appears to be efficient, scar formation and loss of range of movement. It has advantages, Traum 29(5): 309-315. such as the possibility of further correction during the distraction elbow fractures: closing wedge osteotomy and external fixation. Eur J period and it allows early resumption of daily activities. The 5. Song HR, Cho SH, Jeong ST, Park YJ, Koo KH (1997) Supracondylar Ilizarov frame can be removed as an outdoor basis. Bone Joint Surg 79(5): 748-752. osteotomy with Ilizarov fixation for elbow deformities in adults. J References 6. Ilizarov GA (1990) Clinical application of the tension-stress effect for limb lengthening. Clin Orthop 250: 8-26. 1. Barrett IR, Bellemore MC, Kwon YM (1998) Cosmetic results of supracondylar osteotomy for correction of cubitus varus. J Pediatr 7. Paley D (2002) Osteotomy concepts and frontal plane realignment. Orthop 18(4): 445-447. In: Paley D (Eds.), Principles of deformity correction, (1st edn), Berlin Springer-Verlag, Germany, 99-154. 2. Kim HT, Lee Js, Yoo Cl (2005) Management of cubitus varus and valgus. J Bone Joint Surg 87(4): 771-780. 8. Herzenberg JE, Waanders NA (1991) Calculating rate and duration

of distraction for deformity correction with the Ilizarov technique. 9. Bari MM (2013) A color atlas of limb lengthening surgical reconstruction Orthop Clin North 22(4): 601-611. and deformity correction by Ilizarov technique. 330-333.

Citation: Bari MM, Islam S, Shetu NH, Rahman M, Md MB (2015) The Treatment of Cubitus Valgus Using the Ilizarov Method. MOJ Orthop Rheumatol 3(3): 00096. DOI: 10.15406/mojor.2015.03.00096